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Common Otologic Problems

Common Otologic Problems. Diego A. Preciado MD PhD Children’s National Medical Center George Washington University Washington, DC. Impact of pediatric ear disease. Ear related diagnoses are the most common reason for toddler physician visits in the U.S.

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Common Otologic Problems

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  1. Common Otologic Problems Diego A. Preciado MD PhD Children’s National Medical Center George Washington University Washington, DC

  2. Impact of pediatric ear disease • Ear related diagnoses are the most common reason for toddler physician visits in the U.S. • Up to 10,000,000 OM visits/year for 1-4 yr olds Freid, Vital & Health Stats, 1998

  3. Medical proverb • A specialist is someone who learns more and more about less and less until he/she knows everything about nothing • A generalist is someone who learns less and less about more and more until he/she knows nothing about everything

  4. Pediatric residency training • Accurate diagnosis is harder than we may think • Diagnostic accuracy by pediatric residents • CME workshop at 240 locations with 383 pediatric residents • Diagnostic accuracy – video sessions • Resident 41% +/-16 • Pediatrician 51% +/-11 Pichichero ME et al., Pediatrics, 2002

  5. Pediatric residency training • Commitment to training • Survey involving 144 programs participated (64% of all programs) • Only 59% of programs had formal education related to the diagnosis and treatment of OM • Lack of training and availability of diagnostic tools • Survey of 28 family medicine programs • Only 2/3 use pneumatic otoscopy, 1/3 tympanometry • 50% insufficient criteria to diagnose OM • Residents perceived training was adequate MacClements et al., Family Medicine, 2002 Steinbach WJ, Pediatr, 2002.

  6. The otologic exam • Goals for a successful otologic exam • Prevent trauma to the ear canal and tympanic membrane • Safely and effectively remove cerumen • Obtain airtight seal within the external auditory canal • Visualize the entire tympanic membrane

  7. Tools of the trade • Otoscope • Examination of the canal/ tympanic membrane • Cerumen removal • Pneumatic head • Allows for insufflation • Operating head • Foreign body/cerumen removal • Tympanocentesis or middle ear injection

  8. Otoscopic speculae • Ear speculae • Age-appropriate • Ear canal appropriate • Snug for a seal • Provide necessary exposure • Comfortable for the patient

  9. Patient positioning • Gaining the child’s cooperation • Approach each child based on their cognitive developmental level • Distracting and engaging techniques • Positioning • Depends on the age of the patient • Use of ancillary staff and parents

  10. Maximizing exposure • Cerumen removal • Optimize visualization of TM • Atraumatic • Know your limits • Mechanical • Ear curettes • Cerumenolytic drops • Irrigation • Not considered a safe method by AAO-HNS

  11. The otoscopic exam • Pneumatic Otoscopy • Insufflation • assess tympanic membrane mobility • Identification of middle ear fluid improves significantly when subjects were shown pneumatic otoscopy

  12. The otoscopic exam RIGHT EAR, UPRIGHT Pars Flaccida Short process Incus Long process Umbo Pars Tensa

  13. What to look for • Color of TM • Gray, White, Yellow, Pink, Red, Blue • Translucency • Integrity • Mobility of TM • Landmarks • Ear Canal

  14. What’s your diagnosis?

  15. Preinflammatory Acute OE Mild Moderate Severe Chronic OE Edematous skin Erythema, edema of EAC, clear secretions Inc. edema / pain; seropurulent secretions Intense pain, draining secretions, obstructing debris; lymphadenopathy; cellulitis Longer than 4 weeks; 4 infections in 1 year Clinical stages of Otitis Externa Beers & Abramo, Pediatric Emergency Care, 2004

  16. 4 D’s of AOE therapy • Diagnose • Debride • Dry • Drops

  17. Differential diagnosis of AOE • Furunculosis / sebaceous cyst • Otitis media  otitis externa • Mastoiditis • “Wrestler’s ear” / “Cauliflower ear” • Branchial cleft cyst • Trauma • Sensitivity • Myringitis

  18. Bacteriology of AOE DelBeccaro et al, Drugs, 1999

  19. Ototopicals are first line therapy for AOE Oral antibiotics may contribute to emergence of resistance and have therapeutic role only in cases of invasiveness McCoy SI et al 2004 studied the NHAMCS and found among all US visits for OE (1,716,048): 39% Rx topical Abx 25% Rx oral Abx No change in treatment trends from 1995-2000 AOE

  20. AOE • Diagnose, debride, dry, drops • Consider likely micro-organisms • Obtain culture when possible • Preparations for AOE appear equally effective

  21. What’s your diagnosis?

  22. Introduction • AOM is a ubiquitous condition of early childhood with up to 20 million office visits and national cost of $3-$6 billion Grubb, MS and Spaugh DC. Clinical Pediatrics, 2010 http://www.cdc.gov/nchs/ahcd.htm

  23. Acute OM Impact • 42% of all antibiotics prescribed for children are given for the treatment of AOM • Natural history- 80% clinical resolution within first week without treatment • Rosenfeld RM and Kay D. Laryngoscope, 113:1645–1657, 2003 • Increasing concerns about multi-drug resistance among AOM pathogens

  24. To treat or not to treat? • 18 mo old, otherwise healthy • 2 days of 38°C, fussy • Pulling on ears • Crying during the night time • First episode • Flat tymps

  25. Antibiotics in AOMAAP guidelines 2004 AAP Subcommittee on Management of AOM, Pediatrics, 2004

  26. Antibiotics in AOMAAP guidelines 2004 AAP Subcommittee on Management of AOM, Pediatrics, 2004

  27. Mucoid Otitis Media dry Chronic Otitis Media with Effusion Serous Otitis Media 90% No Rx Intact TM Spontaneous perforation Existing perforation wet Chronic Suppurative OM NON Intact TM The Otitis Media Continuum Acute (purulent) Otitis Media RESOLUTION Difficult Rx

  28. What’s your diagnosis?

  29. Otorrhea • 3 main disease types • AOM with perf (non-intact TM) • Chronic Suppurative OM (CSOM) • AOE (INTACT TM)

  30. Bacteriology of AOM Mandel et al. Pediatr, 1995 DelBeccaro et al, J Pediatr, 1992

  31. Bacteriology of CSOM Bluestone CD. Pediatr Infect Dis J, 2001

  32. AOM tympanostomy tube • Clinically and bacteriologically different from AOM • Pathogens of AOM • 50.0% < 6yr • 4.4% > 6 yr • Pathogens of AOM • 52.2% winter months • 14.7% summer months • P. aeruginosa, S. aureus • 43.5% > 6 yr • 44.1% summer months Mandel EM. Ann OtolRhinolLaryngol, 1994

  33. Extracranial Labyrinthitis Mastoiditis Subperiosteal abscess Facial nerve paralysis Cholesteatoma Tympanosclerosis Intracranial Epidural abscess Meningitis Lateral sinus thrombophlebitis Brain abscess Potential Complications of OM

  34. What’s your diagnosis?

  35. Retraction Pocket Theory (Tos) Normal

  36. Tos Type I

  37. Tos Type II

  38. Tos Type III

  39. Tos Type IV

  40. Cholesteatoma

  41. Cholesteatoma

  42. What’s your diagnosis?

  43. What’s your diagnosis?

  44. Congenital Cholesteatoma • Derlacki and Clemis (1965) - “epithelial inclusion behind an intact TM in patient without a history of OM” • Occur secondary to persistent/remnant embryologic epithelial foci in the ME • Usually anterior-superior (2/3)

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